Islamic Republic of Afghanistan Ministry of Public Health General Directorate of Preventive Medicine Communicable Diseases Control Directorate National Malaria and Leishmaniasis Control Programme
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- On-going Community-Based Initiatives in Afghanistan
- Pilot Community-Based Management of Malaria in Badkhshan, Kunduz, and Takhar Provinces
- 6.1 Case Management; prompt and reliable diagnosis and effective treatment
- Strategic Component 2: Capacity Building (Training of health workers and supervisors)
- Strategic Component 3: Advocacy, community sensitization and education
- Strategic Component 4: Risk Management Strategy
- Procurement, storage and distribution
- 8.1 The National Vector Born Disease Control Task Force (VBDCTF)
- 8.2 The Provincial Vector Born Disease Control Task Force (VBDCTF)
- Priorities areas and phased implementation
- 10.1 Integrated supervision
- 10.2 Quality control at point of care
ChallengesPerformance incentive balance for field workers (CHS and CHW) Health services are supported by a multitude of Partners, creating occasional difficulties for coordinated approaches Logistic barriers including limited road access to many parts of the country Lack of clarity over the integration of a historically vertical programme into the BPHS Low salaries/ incentives for Government staff forcing competent staff to supplement their income through private practice or seek employment in the private, NGO or UN sectors where income is higher Limited mobility of women (as professional staff, health workers, household decision-makers, and patients) Ongoing insecurity in some areas of the country Inadequate coverage of population by CHWs On-going Community-Based Initiatives in AfghanistanThe diagnosis of malaria by CHW is currently based on clinical suspicion of malaria (fever without other obvious causes of fever), and, in practice, treatment is based on the co-administration of Chloroquine. The Basic Pack of Heath Services (BPHS) for Afghanistan does not yet include RDTs and ACTs in the CHW kits which are distributed regularly. Several programmes in the country are already implementing community health programmes, engaging the CHWs. Among the ongoing programmes, the following are: Family Health Action Group in 9 provinces of the country, with expansion to additional 4 provinces with support from UNICEF. In these programmes the CHWs are trained in providing health education to the community. With the support of Tech-serve/HSSP there are plans to expand the Post partum family planning program supported by USAID to all 34 provinces of the country. Additional health education programmes have involved school children from grades 1 to 12 to provide health education to their homes and neighbours. The comprehensive 6-months training of CHWs has been completed in 10 Provinces. Community IMCI is being implemented in 16 provinces, with plans for expansion in additional 8 provinces. Growth monitoring program is implemented on a pilot level with the support of BASIC and MoPH/CBHC. Pilot Community-Based Management of Malaria in Badkhshan, Kunduz, and Takhar ProvincesA community-based deployment of ACTs and RDTs was initiated in the Northern provinces of Badkhshan, Kunduz, and Takhar involving community health workers at health post level. In these provinces the pilot project was implemented by Merlin and CAF (Care for Afghan Families), and involved 300 CHWs working in 150 health posts in 18 Districts. A total of 33 CHS have been trained to supervise the CHWs in these project areas (5 in Badkhshan, 14 in Kunduz and 14 in Takhar). One pilot project4, was conducted with WHO TDR funding in 2007-8, evaluated the use of RDTs by six CHWs in Nangahar and Kunduz, A second pilot project will start in 20115 to assess the use of RDTs by community health workers using a randomised trial designin Kunduz and Nangahar Provinces. GOAL To contribute to the improvement of the health status in Afghanistan through the Reduction of morbidity and mortality associated with malaria, by involving CHW. STRATEGIC DIRECTION: To expand access to accurate diagnosis and appropriate treatment for both malaria and non-malarial cases at health post level in all malaria endemic districts. STRATEGIC OBJECTIVES: Objective of CBMM Strategy are objective of National Malaria Strategic Plan 2009-2013 as below: To reduce malaria morbidity by 60% by the year 2013 To reduce malaria mortality by 90% by the year 2013 To reduce the incidence of falciparum malaria to sporadic cases by the end of 2013 with a vision to interrupt transmission of PF Strategic Components: 6.1 Case Management; prompt and reliable diagnosis and effective treatment6.2 Capacity Building (Training of health workers and supervisors)6.3 Advocacy, community sensitization and education6.4 Risk Management StrategyStrategic Component #1: Case Management; prompt and reliable diagnosis and effective treatmentWith the divergence in treatments between vivax and falciparum malaria and relative high cost of ACT compared to chloroquine there is a need for greater emphasis on diagnosis at all levels of the health system; if falciparum malaria is mistakenly treated as vivax treatment failure is assured, and if vivax is treated as falciparum valuable drugs are needlessly wasted. Diagnosis and treatment of malaria should therefore be fully integrated into the general health services. This improves efficiency and coverage and makes better use of limited human and financial resources. Microscopy should be adopted at the BHC level, with priority given to Stratum 1 districts and selected priority areas in Stratum 2. The estimated number of CHCs and BHCs to be targeted for strengthened malaria diagnosis is 670. Moreover, in epidemic situations and wherever malaria microscopy is not feasible RDTs (COMBO) can be used at the community level to distinguish malaria from other causes of fever. RDTs have been tested in Afghanistan and the decision to implement these as opposed to microscopy will be based on cost-effectiveness analysis. Because symptoms of malaria are non-specific, 70-90% of febrile illnesses submitted to microscopic diagnosis are negative (i.e. slide positivity rates are 10-30% or less). Microscopy & RDT diagnosis are needed to reduce wastage of anti-malarial drugs and to improve management of patients who do not have malaria. ACT has been incorporated into the BPHS as an essential drug and is being used for treatment of confirmed falciparum cases. Vivax malaria should continue to be treated with chloroquine. Sustained high-quality diagnosis and treatment of malaria (and other diseases) can only be achieved by regular technical monitoring and quality control of microscopy & RDT by Quality Assurance Centres (QAC) of PHD/PMLCPs under direct supervision and coordination through a national quality assurance unit of MoPH/NMLCP. Targets: By the end of 2013, 80% of targeted Health Posts in stratum 1 districts will be able to diagnose malaria by RDTs and provide treatment according to NTG By the end of 2013, 90% of HSCs, MHTs, in Stratum 1 districts will provide high quality RDT diagnosis and treatment according to NTG By the end of 2015, 100% of HPs, BHCs and HSCs in Stratum 2 and 3 districts will have a continuous supply of ACT+CQ+RDT Strategic Component #2: Capacity Building (Training of health workers and supervisors)A total of 100 master trainers have been trained already, but the involvement of these trainers will allow to train 17000 CHW + 1700 CHS over 2 years (expected to be trained according to the GFR8 grant agreement) for the following reasons: Considering the practice to train 20 trainees per batch, in order to train a total of 18'700 health workers (17'000 CHW + 1'700 CHS) over a total 2 year period a total of 935 training courses will need to be conducted. To complete this, working in pairs, the master trainers will need each to run 19 training courses over a period of 2 year For each health facility 2 health workers should be trained on different periods (in order not to create dysfunctions in the health services), adding complex requirements to the planning and implementation of the training courses. Finally, the target numbers of trainees (17000 CHW + 1700 CHS) during the 2 years of phase I GF R8 implementation seem disproportionately high compared to the total number of CHW and CHS in the country, estimated at 22'000 and 1200, respectively. Based on the above, the total training requirements have been recalculated taking into account the number of health facilities to be included in the CBMM (the number of BHCs without microscopy, HSC and HPs enrolled in the CBMM) and the phased plan for implementation of the CBMM programme (see Table 1 below). The number of HPs per district has been calculated from the maximum number of HPs reporting malaria cases per district through the HMIS in the period April 2009 -January 2010. The new HPs will be enrolled over a two years period: for Stratum 1 over years 2 and 3 and for Stratum the HPs will be enrolled over the years 4 and 5. Since the number of active HPs per district may change is number may change over the 5-years implementation of the CBMM Strategy, the training requirements will be reviewed on an annual basis. Table 1 - Number of health facilities to be involved in the CBMM, during each year of implementation of the strategy
From the above Table, the number of trainees has been calculated, taking into account that 2 health workers will be trained for each of the new BHC, HSC and HP enrolled every year. It is assumed that 10% of new trainees will need to be added every year to compensate for drop-outs of health workers trained the previous year (attrition of health workers at various levels). The supervisors for health workers at BHC and HSC level as well as the Community Health Supervisors (CHS) will also be trained. Their number has been calculated on a ratio of 1/10 per health workers trained. The minimum number of trainers required have been calculated considering the training courses will be implemented through a single-step Training of Trainers (ToT) approach, considering a ratio of 2 trainers for 22 participants (health workers and supervisors), with the possibility of each trainer to complete 3 training courses over a 4 months periods (during the first 2 quarters of each year). An additional 10% of trainers have been also added in view of possible attrition of trainers as well. The overall training requirements are calculated as indicated in the Table 2 below. Table 2 - Number of health workers to be trained, according to the level of implementation of the CBMM
The standard curriculum of training course for health workers on the diagnosis and treatment of malaria will be 2 days. This will be based on the 2-days training course on RDTs as outlined in WHO training manuals6, plus a full extra day will be devoted to disease management, with specific attention to the identification and referral of patients with severe febrile, treatment of uncomplicated malaria with ACTs and chloroquine (for falciparum and vivax malaria , respectively) and patient counselling on when to return. The training tools for trainers and trainees need to be translated in Farsi and Pashtu, and additional training tools (and time allocation in training courses) will be developed to train the community heath supervisors (CHS). The supervisors, including CHS, will receive in addition to the same 3-days basic training course as described above, also one extra half day training on supervision skills, observation, communication and reporting. The training of trainers (master trainers) will be of 4 days duration following the curriculum of the WHO Training of Traininers course which has been developed in Yemen. It will include a 3 days for training of trainers on RDT performance, including teaching and communication skills, quality assurance and programmatic/implementation aspects. This will be following by a full day trainining of trainers on the requirements for disease management and half day of training on supportive supervision (refer to annex 7 for the training curriculum) Strategic Component #3: Advocacy, community sensitization and educationCHS and CHW are conducting "health forum" (2.5 hour) sessions with 10-15 people in the community to share information and education on all aspects related to prevention and treatment of malaria. These education sessions will be repeated at least twice yearly in the communities where the RDTs and ACTs will be deployed as the success of this community-based programme depends on behaviour change for both health providers and consumers. Strategic Component #4: Risk Management StrategyThe implementation strategies in different parts of the country will be reviewed on a quarterly basis, adapting the deployment of ACTs and RDTs at community according to the changing situation. The new data of the malaria surveillance from BHCs without microscopy, HSCs and HPs will be used to refine the estimations on expected number of suspected malaria patients attending these facilities and requiring RDT testing. The emphasis on improved coordination and communication between agencies involved in the implementation of GF R8 malaria grant, with the implementers of BPHS and supporting agencies of CBHC programmes will enable synergies and identification of more sustainable approaches. Close collaboration and communication between all PRs and GFATM secretariat will enable re-programme of the grant to best serve the need of the population of Afghanistan affected by malaria. Allowance will be created to adapt the roll-out plan not only on the basis of malaria stratification, as planned, but also on the basis of dynamic factors which may affect access and operations in different parts of the country. In case the planned high scale-up of implementation of the CBMM strategy at HP level on years 2 and 4 will be operationally not feasible, it is suggested that the roll-out is extended over two years in each phase of the project. Initial priority should be given to districts with higher rates of reporting of falciparum cases. The strong partnership amongst Government of Afghanistan, UN agencies, funding agencies, and national and international NGOs creates an unique environment for implementing effective public health approaches. Procurement, storage and distributionProcurement will be done on yearly basis with staggered deliveries at 6-month intervals of both ACTs and RDTs in order to adjust order quantities and allow flexibility in re-scheduling deliveries in order to minimise risks of over-stocks or stock-outs. Stocks will be kept at the Provincial level and delivery of RDTs and ACTs at Provincial level will be under the responsibility of the Implementing Agencies, i.e. BRAC and HNI-TPO. In principle the ACTs and RDTs should be delivered to the BPHS implementers, in order to avoid the creation of parallel programs. NMCLP Provincial units should be informed of the transfer of diagnostic tests and ACTs from Implementing Agency to the BPHS implementers. Clear guidelines are needed on management of storage and distribution to maintain the RDTs under cool conditions. The Guidelines on Transport, Storing and Handling Malaria Diagnostic Tests in Health Facilities and at Central and Peripheral Storage Facilities, developed by the USAID/Deliver Project will be adapted, translated in Dari & Pashto and duplicated for use in training and programme support activities. Supply to BHCs and HSCs will be based on a "pull system", with demand generated by the BHCs and HSCs. The HPs will be receiving the additional supplies ACTs and RDTs+ancillary items (not yet included in the CHW kits) through the CHCs and/or BHCs which are currently supplying the CHW kits. Delivery of ACTs and RDTs will be managed by the BPHS implementers, without creating new parallel systems. Stock managementThe stock management of ACT and RDTs will be the responsibility of the BPHS implementers, after receiving specific briefing on stock management, temperature monitoring and reporting. Quarterly reports on status of stocks will be provided by the BPHS implementers to NMLCP in order to guide possible re-deployment on of stocks (a loan-basis) according to needs. The NMLCP will keep a limited stock of ACT and RDTs for emergency and response at central level - the replenishment of this stock will need re-programming of GF funds. INSTITUTIONAL FRAMEWORK The Provincial Manager, responsible for the malaria team (often including one epidemiologist, two vector control officer, one IEC officer, two technicians), has the main role of coordinating, monitoring and supervising all malaria control activities in the province, and the malaria-related activities implemented as part of the BPHS. He reports to the Provincial Health Director. The Provincial Project Manager/Focal Point of the Implementing Agency, in close liaison with Provincial Health Director, is responsible for implementation of specific activities of the malaria plan of action in the Province, according to set targets. He/she manages the funds and logistics, and generates specific reports to submit to its funding agencies (to the PR for GFATM-related activities). A LLIN officer, with dedicated staff, is responsible for managing the LLIN distribution campaigns and all related activities, including reporting on these. The Community-Based Health Care (CBHC) Department does not have Provincial unit/teams responsible for coordinating all activities managed at community level. In certain Provinces this function is performed by the PHC unit, and in other a PHD Coordinating Committee is in place to coordinate all programmes and implementing agencies (NGOs). Implementation of the activities by Implementing Agencies (NGOs) is monitored by the Provincial teams, while the central level is responsible for planning, budgeting, training of trainers, data analysis and interpretation, including data from the HMIS relevant to the project, and processing the reports prepared by Provincial managers. MECHANISM FOR COORDINATION In order to bring together the many players which are supporting the Ministry of Public Health in the process of rehabilitating the health services, Task Forces are formed in the health sector to provide a forum for discussion, planning and policy making. These task forces play an important role in coordination and have representation from MoPH, WHO, UNICEF, BPHS implementers, NGOs, and other sectors, including multiple stakeholders and funding agencies. The NMLCP has a task force to coordinate prevention and control activities related to malaria named as VBDCTF (Vector Born Disease Control Task Force), which is operational at both National and Provincial Levels. 8.1 The National Vector Born Disease Control Task Force (VBDCTF)The Vector Born Disease Control Task Force (VBDCTF) aims to promote, design, monitor and implement malaria and leishmaniasis control within the framework of relevant policy documents (i.e. BPHS, NMSP, EPHS and other relevant policies). The MoPH is the leading agency if the VBDCTF on issues related to policy and implementation of control of malaria, leismaniasis and other vector-born diseases; all members coordinate closely with the relevant Department of the MoPH, which is the National Malaria and Leishmaniasis Control Programme. The VBDCTF represents the main technical and policy forum for the control of malaria, leishmaniasis and other vector born diseases in Afghanistan. When possible, all changes in malaria control policy should be approved by consensus by the VBDCTF. In its decision making the VBDCTF reviews the scientific, technical and programmatic evidence before making policy decisions to ensure evidence-based programme implementation. The VBDCTF promotes the control of malaria, leishmaniasis and other vector born diseases at all levels of government, health sector and other sectors. It also oversees the achievement of the relevant Millennium Development Goals and other nationally approved development targets. It promotes equity in the health sector, particularly concerning the role of women. The VBDCTF maximises the effectiveness of activities through coordination of activities among all members. It also provides an information and technical knowledge forum for sharing of information and technical updates. It advocates for funding of projects which aim to prevent and control malaria, leismaniasis and other vector-born diseases. Permanent Members of VBDCTF: MoPH: Manager Program support coordinator, NMLCP technical advisor, other NMLCP staff as an appropriate. WHO: WHO Medical Officer, Afghanistan, and other WHO staff as appropriate NGOs: Health Net-TPO, BRAC, ACTD, HPRO Non-permanent Members of VBDCTF: The VBDCTF may invite either permanently, or on ad hoc basis other partners or organisations, such as funding agencies, media, members of other task-force of MoPH, as may be necessary to reach the objectives of the task force. Mode of Action: The VBDCTF will meet on the second Wednesday of each month at 10AM. In case of any urgent issue, NMLCP manger may convene the task force before the mentioned date. The meetings are called and organised by the Manager NMLCP (or his representative). There is no specific budget to cover the cost of the attending VBDCTF meeting in any such cost must be born by the organizations represented by the member. Decisions will be made by consensus and transparently. In the event that consensus cannot be reached then the permanent members will attempt to achieve consensus. If this fails, then the NMLCP Manager has the final say. Minutes of the meetings are public documents; they shall be communicated IN DRAFT form to permanent members. Once finalised and approved; minutes shall be communicated to all members, who are free to distribute them as they see fit. 8.2 The Provincial Vector Born Disease Control Task Force (VBDCTF)The same structure established at central level is also present at Provincial level under the coordination of the Provincial Public Health Directorate. At Provincial level the following members contribute to the work of the Task Force: PHD: Provincial Public Health Director, Provincial Malaria & Leishmaniasis Control Program Manager, Provincial CDC Manager, PHA, Provincial TB Manager, Provincial HMIS Manager, BPHS Implementer. NGOs: HealthNet TPO and BRAC IMPLEMENTATION PLAN Priorities areas and phased implementationThe Community-Based Management of Malaria (CBMM) strategy will be implemented in a phased manner during the 5 years period 2011-2015. Year 1: ACT+CQ+RDT deployment in all BHCs (without microscopy) and HSCs in all Districts in Stratum 1 and in 150 Health Posts (to continue the pilot project) The continuation of the CBMM pilot project in 150 Health Posts (involving 300 CHWs and 33 CHS), in the 18 districts of Badakhshan , Kunduz and Takhar, will help to consolidate the lessons learnt and guide the implementation of the community-based management of malaria to all Health Posts in all HP of Districts in Stratum 1, in Year 2. Moreover, consolidated experience in the use of RDTs in BHC and HSC will be important to ensure supervision and support to CHW from the same catchment areas involved in these activities. Year 2: ACT+CQ+RDT deployment in all BHCs (without microscopy), HSCs as well as in all HPs of Districts in Stratum 1 This phased, yet large-scale, deployment of CBMM in years 1 and 2, will allow to acquire experience and data on programmatic requirements for implementation of this strategy in the remaining part of the country. It will also allow to refine supervision and support systems, as well as to improve the cost-effectiveness of the interventions. The focus on districts with higher malaria burden (Stratum 1) during the first two years of the project will also enable further improvement of the malaria stratification in the country. Since most of the reported malaria cases are only clinical suspected malaria cases (not confirmed by microscopy), this strategy will prioritize the introduction of malaria diagnosis by RDTs for areas where the majority of cases are reported based on clinical diagnosis alone. The further extension of the CBMM in years 3, 4, and 5 will be phased as described below, up to the total extension of the strategy to the whole country. Year 3: Same as Year 2 plus ACT+CQ+RDT deployment in all BHCs (without microscopy) and HSCs in all low risk Districts of Stratum 2 and Stratum 3 Year 4: Same as Year 3 plus ACT+CQ+RDT deployment in all HPs in low risk Districts (Stratum 2+3) Year 5: Same as Year 4, with consolidation of results and further increase of coverage targets (see Table 3 below) MONITORING AND EVALUATION The relevant data collection forms which will used at BHC, HSC and HP levels will be developed by NMLCP in collaboration with HIMS Department to include ACT treatment and testing by RDTs. As much as possible existing data flow and reporting system will be used to monitor the implementation of the programme. Key indicators (outcome and impact) specific for surveys will be implemented to monitor the effectiveness of the programme. In line with the national malaria control strategic plan (2008-2013) the programme implementation will be monitored on the basis of the data and indicators listed in Table 3, below. 10.1 Integrated supervisionA specific checklist has been developed during the implementation of the CBMM in the pilot districts (see Annex 4). This will be reviewed and adapted for use in the whole programme. The supervision of CHWs will be performed by CHS. While CHS are paid by BPHS implementers, the CBMM implementing agencies (BRAC and HNI-TPO) will cover the additional costs to supervise the CBMM-related activities. Standard reimbursement fees for transport and other activities for both CHS and CHWs will be defined in close collaboration with CBHC and implementing partners. For the supervision of BHC and HSC, programme supervisors from the Implementing Agencies will be involved, and they will need to receive a specific training to assess the quality of malaria case management in health facilities. 10.2 Quality control at point of careThe main activities to control the quality of RDTs and ACTs deployment at point of care should be part of the supervision visits by CHS and programme supervisors and focus on: 1) conditions of storage; 2) checking temperature monitoring charts; 3) direct observation of health workers in performing the test, interpreting the results, dispensing the treatment and recording the data on case, results and treatment. Monitoring of the daily max temperature of the warehouses in areas exposed to high temperature will be done before and during the implementation phase. The temperature monitoring charts with minimum-maximum thermometer should be available in all health facilities and warehouses in all places where the daily temperature is expected to exceed 30 °C. Table 3 - Key indicators to monitor inputs, process, outcome of CBMM programm
The HMIS data flow in relation to malaria reporting at Provincial and Central levels is shown in the Figure 6 below. 
Figure 6. Reporting data flow (HMIS and other reporting systems relevant to CBMM) Directory: Content -> Media -> Documents Media -> Black Watch – press and marketing pack Contents Media -> 2015 chevrolet silverado 1500 New for 2015 Media -> Citizens Theatre, Glasgow: Wed 23 – Sat 26 March Macphail Theatre, Ullapool Media -> Epa vehicle class Media -> 2016 chevrolet tahoe vehicle highlights Media -> 2015 chevrolet corvette stingray new for 2015 Media -> Opel History 1900-1909 Documents -> Islamic Republic of Afghanistan Ministry of Public Health General Directorate of Preventive Medicine and Primary Health Care, National Malaria and Leishmaniasis Control Programme Draft National Malaria Strategic Plan Download 5.6 Mb. Share with your friends:
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